MetLife uses this six-page statement to gather the medical information it needs to decide or continue a group short-term or long-term disability claim. A clinician usually meets it when the MetLife case manager asks the patient for new or updated medical information. The treating physician reports diagnosis codes, treatment history, return-to-work advice and hour-by-hour physical capacities, then sends all pages with office notes and test results to MetLife Disability.
The physician treating the disabling condition completes Section 2 and signs Section 3. The employee completes Section 1 with name, date of birth, employer and claim number.
MetLife uses the form to collect the information needed to process the patient's claim for disability benefits. The opening notes warn that submitting an incomplete form may delay claim processing and ask that the claim number be written on any additional records sent with it. A New York fraud warning appears on the first page, and the full set of state fraud warnings follows on pages 5 and 6.
Enter the claimant's first, middle and last name, date of birth, employer name and MetLife claim number. The claim number ties the statement to the open claim, and Section 4 asks for it again at the top of every page before the form and any supporting records are sent.
The physician providing treatment for the disabling condition completes this section, and MetLife states the information will be used in deciding the patient's claim. Under About The Diagnosis And Treatment Of Your Patient, give the primary and secondary diagnosis codes with descriptions. Under History Of Your Patient's Condition, enter the first date of treatment for this condition, the most recent office visit and the next scheduled visit.
For a pregnancy-related condition, check cesarean, natural birth or not yet delivered and give the actual or expected delivery date. Answer whether the condition is work related, whether you advised the patient to stop working and when, and whether the patient was hospitalized, with facility details. Then list the reported symptoms, your clinical findings with copies of results, the recommended treatment plan, and any performed or anticipated surgery with its CPT-4 code and date.
State whether you have advised the patient when they can return to work, to their regular occupation or to any other occupation, on what date and with or without restrictions; if not, explain. Then answer whether the patient is at maximum medical improvement, whether they can work 8 or 12 hours a day with standard breaks, how many hours a day they can work if not full-time, and whether they are right- or left-hand dominant.
Give your opinion of the hours per day the patient can sit, stand, walk, climb, balance, stoop, kneel, crouch, crawl, reach, handle, finger, use a keyboard and mouse and operate a vehicle or machinery, from no restriction through constantly (more than 5.5 hours), frequently, occasionally or never, marking right, left or bilateral where asked. Rate lifting, carrying, pushing and pulling from sedentary to very heavy, add any other restrictions and state their anticipated duration.
First list any other physicians or specialists you referred the patient to, with their specialty. Then enter your name, address, degree or specialty, office phone and fax, Tax ID and email, with an optional checkbox allowing MetLife Disability to email your office with requests for information about this patient. Sign and date the statement.
Send all pages of the form and any supporting documents to MetLife Disability by mail or fax, adding the claim number to the top of each page. Section 2 asks that office notes and diagnostic results related to the patient's condition, such as x-ray, lab, EKG or MRI reports, go with the completed form.
Download the current version from the source each time; forms change without notice.
Disability Claims Attending Physician Statement
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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MetLife's forms library says the patient should have their physician complete this form when the case manager requests new or updated medical information. MetLife describes it as gathering the medical information needed for the ongoing management of disability claims, so it supports decisions on starting or continuing short-term and long-term disability benefits.
Section 1 identifies the patient and claim. The treating physician completes Section 2, covering diagnosis codes, treatment history, pregnancy, symptoms, findings, treatment plan, return to work and physical capacities, and signs Section 3 with contact details and Tax ID. Section 4 explains how to send the form, with the claim number on each page.
Section 2 asks the physician to submit the form with office notes and results from any diagnostic testing related to the condition, such as x-rays, lab tests, EKGs or MRIs, including copies of results behind the clinical findings. MetLife asks for the claim number on any additional records and warns that an incomplete form may delay processing.
Not in the current edition. The 12/24 version of APS-STD-LTD-5320 covers both short-term and long-term disability and has a pregnancy checkbox for cesarean, natural birth or not yet delivered, with the actual or expected delivery date, in place of a separate maternity statement.